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J Endocr Soc ; 6(Suppl 1):A820-1, 2022.
Article in English | PubMed Central | ID: covidwho-2119784


Background: COVID-19 infection affects multiple organ systems including the endocrine system. Its effect on thyroid function has been reported in multiple studies and one of them observed overt thyrotoxicosis in 10.8% of COVID-19 hospitalized patients associated with higher mortality and longer hospital stays. There is paucity of data on the impact of COVID-19 in patients with pre-existing hyperthyroidism, with only few case reports highlighting the clinical course of such patients. We report a young woman diagnosed with Graves’ disease (GD) who was admitted 4 weeks later with thyroid storm precipitated by COVID-19. Case: An 18 year old woman presented to the Emergency Room (ER) with fatigue, palpitations, diaphoresis, and diarrhea for 2 weeks. She had sinus tachycardia with heart rate (HR) of 118 beats per minute (bpm). She had diffuse thyromegaly and fine tremors on exam. TSH was < 0.01 uIU/mL and free Thyroxine (FT4) >8 ng/dL. Thyroid Stimulating Immunoglobulin (TSI) was elevated consistent with GD. She was admitted and treated with intravenous fluids (IV), propranolol and methimazole with significant improvement. She was discharged on methimazole and propranolol. FT4 improved to 3.31 ng/dL 3 weeks later with 100% medication compliance. A week later, patient visited ER due to sore throat, left earache, and dry cough. Influenza PCR and COVID-19 nasal antigen tests were negative, and patient was discharged on amoxicillin-clavulanate for suspected otitis media and acute pharyngitis. Her symptoms worsened over the next few days and she was admitted again with nausea, vomiting, anxiety, palpitations, dyspnea and diarrhea. She was febrile to 101F, HR 135 bpm with agitation and reduced concentration. Burch-Wartofsky score was 65, highly suggestive of thyroid storm. FT4 was elevated at 4.46 ng/dL. COVID-19 PCR was positive. She was treated with propylthiouracil, propranolol and IV hydrocortisone with gradual improvement in symptoms. She was discharged on methimazole, propranolol and prednisone 10 mg for 10 days. Due to worsening hyperthyroid symptoms and rise in FT4, 1 week after stopping prednisone, it was restarted, and an urgent out-patient surgical referral was placed. She was advised to repeat thyroid labs in 1 week. Conclusion: Thyroid storm is a rare, life-threatening endocrine emergency with a mortality rate of 10-30% that demands prompt recognition and timely intervention. Our case highlights that there must be a high index of suspicion for COVID-19 with worsening hyperthyroidism in patients with GD who are compliant with anti-thyroid medication especially if they have upper or lower respiratory tract symptoms. Patients with GD should be closely monitored during COVID-19 infection for development of thyroid storm. Early initiation of steroids might be considered with worsening thyroid function despite normal respiratory status to counteract inflammatory thyroiditis. Further studies will be useful to see the effect of COVID-19 infection in patients with GD.Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Endocrine Practice ; 27(6):S5, 2021.
Article in English | EMBASE | ID: covidwho-1859539


Introduction: Nelson syndrome has been reported in up to 25% of adults after bilateral adrenalectomy (BLA) for Cushing’s disease (CD). It usually manifests as an expanding pituitary mass, rising adrenocorticotropic (ACTH) hormone levels and, in many patients, the development of hyperpigmentation. We review the clinical course of a patient with rising ACTH levels after BLA for presumed CD. Although the diagnosis of Nelson syndrome was considered, he was found 9 years after BLA to have an ectopic ACTH secreting bronchial carcinoid tumor as a cause for the elevated ACTH levels. Case Description: A 35 year old male was evaluated at another institution in 2010 after he presented with weight gain, new onset hypertension, muscle weakness with multiple falls, depression, irritability and emotional lability. He was diagnosed with CD and was referred to a university center where he underwent trans-sphenoidal pituitary surgery in May 2011. An adenoma was seen on frozen section but not on the final pathology. He developed transient symptoms of adrenal insufficiency on the second post-operative day. Because of persistent hypercortisolism he underwent BLA in November 2011. We started following him in 2012 and signs of hypercortisolism gradually resolved. He appeared euadrenal on hydrocortisone 10 mg am, 5 mg 12 noon and 5 mg 6 pm and fludrocortisone 0.05 mg daily. ACTH levels increased from 54 pg/ml (6-50) in 2012 to 1024 pg/ml in 2019. He had no hyperpigmentation and MRI of the pituitary from 2014-20 did not show a pituitary mass. During an evaluation for COVID-19 infection in May 2020, a chest x ray revealed a right lower lobe lung mass measuring 3.3 x 2.0 cm. He underwent right lower lobe lung lobectomy in July 2020 and pathology revealed a carcinoid tumor-spindle cell pattern which stained strongly positive for ACTH and weakly positive for chromogranin. ACTH levels after the surgery decreased to 16.3 pg/ml. Discussion: Some authors have suggested that Nelson syndrome be considered in patients with BLA who have one of the following: an expanding pituitary mass or ACTH levels >500 p/ml at 3 different time points after surgery. This case highlights the need to consider ectopic ACTH syndrome as another cause for rising ACTH levels after BLA for CD especially in those patients who are not found to have a discreet adenoma after pituitary surgery.

Nephrology Dialysis Transplantation ; 36(SUPPL 1):i245-i246, 2021.
Article in English | EMBASE | ID: covidwho-1402418


BACKGROUND AND AIMS: Initial WHO guidance advised cautious fluid administration for patients with COVID-19 due to concern about the development of acute respiratory distress syndrome (ARDS). However, as the pandemic unfolded it became apparent that patients who were admitted to hospital had high rates of AKI and this initiated a change in local clinical guidelines during early April 2020. We aimed to ascertain the impact of judicious intravenous fluid use on mortality, length of hospitalisation and AKI. METHOD: An observational cohort study of 158 adults admitted with confirmed SARS-Cov-2 between 18th March and 9th May 2020 was conducted in a teaching hospital and designated centre for infectious diseases, London, UK. Key clinical and demographic data collected included clinical severity markers on admission, biochemical and haematological parameters as well as radiological findings. Primary outcomes were inpatient mortality, mortality at 6-weeks post discharge, length of hospitalisation and intensive care (ICU) admission. We also measured requirement for kidney replacement therapy (KRT) and AKI recovery rate at discharge. Using tests of difference, we compared key outcomes between patients treated with varying fluid regimens and then identified risk factors for AKI and mortality using multivariate logistic regression with results expressed as odds ratios (OR) with corresponding 95% confidence interval (CI). RESULTS: The median age was 74.4 (IQR 59.90 - 84.35) years, 66% were male, 53% white with hypertension and diabetes being the commonest co-morbidities. The median duration of illness prior to admission was 7 days (IQR 2 - 10) with respiratory symptoms and fever most prevalent. The people who presented with AKI on admission were more likely to receive fluids (34% vs 15%, p=0.02). 118 patients (75%) received fluids within 24-hours of admission with no difference in volume administered after local guidance change (p=0.78). Comparing patients receiving fluids with those who did not, we observed no difference in mortality (p=0.97), duration of hospital stays (p=0.26) or requirement for ICU admission (p=0.70). 18% died as an inpatient, and 52 patients were either admitted with or developed AKI. Of these 52 patients, 43 received fluids and 9 did not with no difference in KRT requirement (p=0.34), mortality (p=0.50) or AKI recovery (p=0.63). Peak AKI stage was greater among participants who received fluids though stage of AKI at presentation was also greater (p=0.04). Mortality rate in patients with an AKI is higher compared to overall inpatient mortality (31% vs 18%). Of the 36 patients with AKI (Figure Presnted) who were discharged home, 25 patients (69.4%) had renal recovery by the time of discharge. Increasing age and clinical severity on admission were associated with higher mortality (see Figure 1). Older age was associated with 34 - 53 times higher risk of death compared with those aged ≥ 65 years (age 76 - 85 years: OR 34.26, 95% CI: 3.94 - 297.48, p=0.001;age > 85 years: OR 53.07, 95% CI: 5.23 - 539.03, p=0.001). Patients with NEWS2 >4 on admission has 5-fold increased risk of death than those with a score ≥4 (OR 5.26, 95% CI: 1.32 - 20.92). Black ethnicity was associated with a 16-fold increased risk of developing AKI (OR 15.86, 95% CI: 1.67 - 150.99). CONCLUSION: To our knowledge, this is the first study to examine the impact of fluid management on inpatient mortality as well as on renal-associated outcomes of COVID-19 admission. Fluid administration regimen did not have an impact on mortality, length of hospitalisation or ICU admission, nor did it affect renal outcomes. Given the high rates of AKI and KRT in COVID-19 disease, early fluid administration is likely to be an important cornerstone of future management. Further adequately powered prospective studies are required to identify whether early fluid administration can reduce renal injury.